Consults - New York Times Blog
December 27, 2010, 3:04 pm
Expert Answers on Alopecia
By THE NEW YORK TIMES

In today’s Science Times, Claudia Dreifus interviews Angela Christiano, a researcher who began studying hair loss after a hairdresser discovered a bald spot at the back of her head. She has since discovered several genes that contribute to alopecia areata, a fairly common condition that causes hair loss, either in discrete patches or all over the body.
Wilma Bergfeld, M.D.

Dozens of readers had questions about alopecia areata when it was featured earlier this year in an installment of the Patient Voices multimedia series and in Science Times, “A ‘Forest Fire of Hair Loss’ and Its Scars.” This week, Dr. Wilma F. Bergfeld, a dermatologist at the Cleveland Clinic and an expert on hair disorders, joins the Consults blog to answer many of these questions. Dr. Bergfeld serves as director of the dermatopathology fellowship and professor of dermatology and pathology at the Cleveland Clinic Educational Foundation and is also an asssociate clinical professor in the department of dermatology at Case Western Reserve University. See her responses below.

Is Alopecia a Lifelong Condition?
Q.

When my daughter was 9 she was diagnosed with alopecia areata and eventually lost about 90 percent of the hair on her head. She tried many treatments, including steroids and other topical treatments, including daily application of men’s Rogaine, but none appeared to work. At age 13, she entered puberty and spontaneously began to grow her hair back, and now at age 17, she has more hair on her head than anyone I know.

I am wondering if there is a time after which she can have some assurance that she will not lose her hair again? If she goes, say, five years with no signs of bald patches, is there a greater chance that she will not lose her hair again? Are there any warning signs, other than the appearance of a bald patch, that she may be about to lose her hair ?
cf, New York
A.

Dr. Bergfeld responds:

Alopecia areata is a lifelong disorder. Most individuals have patches of hair loss that come and go with triggers: stress, metabolic or endocrine disorders, and even nutritional deficiencies. Alopecia totalis, which involves loss of all the hair on the scalp, accounts for about 20 percent of all cases of alopecia areata. Once alopecia totalis occurs, there is a heightened tendency for it to recur. It is prudent to treat even patchy alopecia areata in these types of patients.
Q.

When my son was 7, he lost all of his hair over Christmas break. He left school with a full head of hair and returned two weeks later with no hair on his head and very few eyebrows or eyelashes. Because our family had just lost my son’s favorite cousin, everyone assumed it was related to grief and trauma. Doctors disagreed. He is now 9 and has the universalis form.

We were initially told that the longer the hair loss continues, the less likely it is that he will ever regrow hair. But from what I read, the alopecia is permanent, although some people have periods of hair regrowth. From a medical viewpoint, should we consider this a lifetime condition?
Awilson, Ohio
A.

Dr. Bergfeld responds:

Alopecia universalis, which involves loss of scalp and body hair, is rare and the most difficult form of alopecia areata to treat. Spontaneous regrowth can occur but is rare. The most effective treatments are the sensitization therapies that induce a contact dermatitis on the scalp. Even a patient with alopecia universalis can be treated with this method. About 30 to 60 percent of patients will respond.

Your son should also be evaluated to see if other autoimmune and endocrine disorders may be present and, if so, they should be treated. This approach will increase the possibility of hair regrowth.

Lifetime Risk of Alopecia
Q.

Please clarify the lifetime risk for alopecia areata and the prevalence of people in the U.S. who are currently estimated to have a form of it.

My understanding has been that 2 percent of the population have a lifetime risk for some form, including transient, patchy occurrences, while the prevalence of people at one point in time is estimated to be only 0.1 percent to 0.2 percent of the population. Thank you.
Thea Chassin, Bald Girls Do Lunch Inc, Scarborough, N.Y.
A.

Dr. Bergfeld responds:

You are correct. Two percent of the population is at risk of developing alopecia. Of that group, only 20 percent have alopecia totalis or alopecia universalis, the rarest form. The disease is frequently associated with allergies, thyroid disorders and, less commonly, with Crohn’s disease, Type 2 diabetes and other autoimmune diseases.

Balding in Men

Is alopecia hereditary? My grandfather suffered from it, when he was about 60, and he seemed to lose all his hair. Am I likely to suffer from the same complaint, now that I am the same age?
Alan Davison, Brussels
A.

Dr. Bergfeld responds:

It sounds like you’re talking about male pattern hair loss, or alopecia, which is inherited. The gene is carried on the X chromosome. It is thought to be an autosomal dominant disorder with variable penetrance, with the most dominant line passed through the mother. You likely have about a one in four chance of having male pattern hair loss. Genes have also been identified for alopecia areata; the area is under active investigation.

Testing for Alopecia
Q.

Is there a way to get tested for these genes?
U.V., Wallkill, N.Y.
A.

Dr. Bergfeld responds:

There is currently one lab that is advertising a gene test of male or female pattern hair loss.

A standardized gene test for alopecia areata, however, is not yet available. We are probably several years away from such a test. Check with the National Alopecia Areata Foundation Web site.This group is actively advocating for such a test.

Passing Alopecia On to Your Children
Q.

Thanks very much for taking comments and questions. My husband has alopecia universalis. Can I find out if he has passed it on to our kids?
Rosemary, Chicago
A.

Dr. Bergfeld responds:

There is about a 7 percent chance that offspring will display the condition, but 25 percent of children may carry the gene for alopecia universalis.

Is Stress Related to Hair Loss?
Q.

Is alopecia areata really caused by stress, or is that just a phrase for ‘we don’t know what causes it’? Not all alopecia areata patients — such as children — are high-strung people.
Jb, Washington, D.C.
Q.

Dr. Bergfeld responds:

Stress mobilizes a steroid hormone response body-wide, as well as locally at the target hair follicle. With the increase in several androgenic hormones (related to the male hormone androgen), especially from the adrenal gland, hair can be prematurely shed.
Q.

I know the official party line is that alopecia is not caused by stress, but there are many (somewhat less than reliable) sources that say it can be. The months before my initial hair loss were filled with the worst emotional pain and anxiety I have ever experienced in my life. Could you comment on the connection?
Wilifred, Seattle
A.

Dr. Bergfeld responds:

Depending on the level of stress, a minor to severe shed can be initiated. Usually there is minor shedding of hair two to four weeks following an episode of stress, but at six weeks to four months, there can be a gradual and persistent hair loss that lasts about four months if the trigger disappears. Even if stress remains, the shedding may stabilize and not increase but be higher then normal. The key is to stop the trigger/stress or reduce it.

[See also Dr. Maria Hordinsky's earlier comments in "Can Stress Cause Hair Loss?"]

Treatments for the Hair Loss of Alopecia
Q.

This article is very timely for me. I found my first bald patch back in February. It was small, not readily visible, and already had hair growing back in, so my doctor and I took a wait-and-see approach.

Some hair grew in, but the patch kept getting larger. Last week I found a second patch and decided the time for waiting is over.

We are starting with topical steroids, and if I do not have improvement, we are moving on to injections.

Is there anything more that can be done other than steroids and waiting? And saving for a good wig, should the need arise?
Wilifred, Seattle
A.

Dr. Bergfeld responds:

Your approach is a good initial therapy. I would add Coal Tar shampoo, and multivitamins with iron and zinc.

Visiting a Dermatologist
Q.

I am a female with alopecia areata — significant patchy hair loss on my scalp (it moves around, growing back in some areas, losing in others, but always in distinct patches over an inch in size). I’ve had it since I was 22 years old. I am one of those who suspect stress is a trigger. My question is, I have not attempted any treatment since my mid-20s, now 20 years ago. For substantial (over 40 percent) hair loss, are there any promising treatments that might make it worth a visit to a dermatologist?
Kim, Houston
A.

Dr. Bergfeld responds:

My advice is to find a dermatologist who specializes in hair disorders. With such a doctor, you may have a good chance of treating and stabilizing the alopecia areata, with ultimate regrowth of hair.

Is Hair Loss Related to Hormones or Pregnancy?
Q.

I have had alopecia areata on and off since my early 30s (I am now 49). The first time I noticed small quarter-sized dots of hair loss was when I was pregnant with my first child. When I was 42, I had my third child and nursed her for three years. When I stopped nursing all of my hair fell out. It was awful! It has since grown back even fuller than before, and I have been able to keep the hair loss spots under control by using extra-strength Rogaine on my scalp once a day. It really seems to be working. My hair loss is always preceded by pain and a very tender scalp or itching in the area where the hair falls out. The Rogaine seems to prevent that from happening.

I guess my question is: my hair loss seems to be somehow related to hormones in some way. Has there been any new research on the connection between alopecia areata and female hormones/pregnancy?
Pegnation, Hoboken, N.J.
A.

Dr. Bergfeld responds:

The usual hair loss that occurs after delivering a baby is called telogen effluvium, and the shedding is generally self-limiting. However, prolonged breast-feeding can lead to both nutritional and hormonal problems. Supplemental vitamins, such as prenatal vitamins with iron, should therefore be taken during breast-feeding.

What you describe, though, is alopecia areata, which can also occur postpartum, though it is rare. The condition is generally associated with tenderness of scalp skin prior to loss of hair. Treatments for alopecia areata could be helpful and would include tar shampoo, topical steroids and seeing a dermatologist for evaluation.

Alopecia and Jewish Ancestry
Q.

I am wondering about the connection between alopecia and hormonal changes, as well as what has been reported to me as a higher incidence of this condition in Jews of Ashkenazic descent. I also have Hashimoto’s thyroiditis.
ml, Mill Valley, Calif.
A.

Dr. Bergfeld responds:

Alopecia areata is inherited and associated with autoimmune diseases like Hashimoto’s thyroiditis. Triggers for expression include stress and metabolic and endocrine disorders.

I am unaware that there are specific ethnic groups that have a higher prevalence of alopecia areata. The disease occurs in all populations.

Is Menopause Related to the Hair Loss of Alopecia?
Q.

I am a 55-year-old female. In the last year year or so, I have lost about three-fourths of the hair on my head and most of the hair on the rest of my body. My TSH is normal. I have taken hydrochlorthiazide for about six years; no other meds. My internist and dermatologist say “it’s just menopause.” Is there anything else to try or consider?
D.M., Boston
A.

Dr. Bergfeld responds:

If you have no risk factors, hormone replacement could be a helpful treatment. Topical Rogaine solution or foam could be helpful for treatment of your scalp hair loss.

In menopause, it is usual to lose body hair and have increased facial hair. This is a result of reversal of the estrogen/testosterone ratio.

Is Alopecia Linked to Infertility?
Q.

I am also struggling with infertility issues and I am wondering if others with alopecia face this challenge, and is there is a link? We have done a lot of testing, but nothing has come up positive. Thanks!
LN, Boston
A.

Dr. Bergfeld responds:

There can be a link between alopecia and fertility issues. You should be evaluated for polycystic ovary disease as well as androgen excess syndrome (metabolic syndrome).

Seborrhea-Alopecia Link?
Q.

@sophie in vienna: I posted earlier, but would like to comment that after me you are the only person to mention seborrhea in connection with alopecia. Still, I think that the two may go together in many more instances than physicians and patients notice. I also would appreciate the doctor’s comment on this pairing. Thanks.
Miriam, Va
A.

Dr. Bergfeld responds:

Inflammation of the scalp does alter the hair growth cycle and can begin to short-circuit it. The hair fibers get smaller and have a shorter life cycle. Seborrheic dermatitis produces scalp inflammation. It is also caused by a yeast organism that actually reduces hair growth.

Autoimmune Disorders and Alopecia
Q.

I would also like to know how this relates to other autoimmune disorders. I have a sister with MS [multiple sclerosis], Mom has RA [rheumatoid arthritis], my brother and I have IBS [irritable bowel syndrome], and I have asthma and allergies.
Wilifred, Seattle
A.

Dr. Bergfeld responds:

Hair loss can be a feature of autoimmune diseases, including multiple sclerosis, rheumatoid arthritis and allergies. It can also be related to thyroid function. Irritable bowel syndrome is associated with stress and reduced absorption of needed nutrients in the gut; both can cause hair loss.

Celiac Disease and Alopecia
Q.

Some celiacs, another autoimmune disorder, have alopecia. The genetic link is under study. http://celiacdisease.about.com…
utenNoCasein, SE USA
A.

Dr. Bergfeld responds:

Celiac disease is an autoimmune and metabolic disorder, and hair loss can occur, but the cause is related to lack of absorption of needed nutrients and stress, as well as a possible association with other autoimmune diseases.

Is Vitiligo Related to Alopecia?
Q.

Hello, I am a 34-year-old female. Eight years ago, on the eve of being married, I developed both alopecia areata and vitiligo. The alopecia first presented itself as a quarter-size patch on the back of my head, but I later lost hair near my front hairline and was forced to cut bangs to cover it. My hair has since grown back of its own accord and I have not experienced any further alopecia.

I treated my two de-pigmented vitiligo spots, one of which was situated near my eyebrow and resulted in the loss of a quarter of my eyebrow, with protopic. My de-pigmentation became less noticeable, but is still present. My eyebrow grew back, though I now have a few stark white hairs at my inner eyebrow. I have developed no new vitiligo spots.

I wonder if these two conditions may be related, and what steps I might take to avoid outbreaks of either again in future. Thank you.
MAB, Baltimore
A.

Dr. Bergfeld responds:

Alopecia areata and vitiligo are two distinct autoimmune diseases, and both can occur together. A dermatologist can help.

Psoriasis and Alopecia Link?
Q.

Curiously, after reading that alopecia and psoriasis were thought to be closely related: I must mention that my identical twin brother began suffering from psoriasis at approximately the same time that I started to have intermittent alopecia areata.
libelul
A.

Dr. Bergfeld responds:

Any disease affecting the skin of the scalp can reduce hair cycling and growth.

Nail Problems Related to Hair Problems?
Q.

I discovered one bald spot on the back of my head in December ‘09 and within two months I was diagnosed with alopecia universalis when all of the hair had fallen out. Since that time, I have been dealing with my fingernails thinning out. Currently they are scratched, discolored and depressed with increased sensitivity due to the thin nail.

Is there a chance my fingernails could fall out completely?
Klahd222, New York, N.Y.
A.

Dr. Bergfeld responds:

Nail problems are seen with alopecia areata, the most common of which is pitting. Severe nail changes are most commonly associated with alopecia universalis. Usually even in the worst nail disorders, though, the nail is not lost but becomes very thin.

Can Drugs Cause Hair Loss? Are Redheads at Higher Risk?
Q.

My sister found a bald spot on the back of her head about three weeks after taking a well-known, now OTC, allergy drug (Claritin). Within a few months, she was completely hairless over her entire body. This occurred about eight years ago, and she is in her 30s.

While I sympathize with the gentleman in the story (“A Forest Fire of Hair Loss and its Scars”), alopecia is devastating to young women, for whom baldness is not expected. What’s more, it has been difficult — if not impossible — to report this adverse reaction to a common drug to the FDA. Yes, we completed a MedWatch form, although her doctor was less than helpful in that process.

Where do patients go to get information about drug-caused alopecia? Are there any resources to help educate physicians about the possible repercussions of these drugs? We learned in what research was available that the key ingredient of the drug causes follicle death. We also learned that less than 5 percent of clinical trial participants are redheads (which my sister also is), and further, that fair-skinned redheads are especially sensitive to these types of drugs.

I don’t believe this is limited to just a problem gene. I also don’t believe most doctors know these things about certain drugs, about the sensitivity of redheads and fair people, etc. What would you advise?
Thinkhealthy, Cambridge, Mass.
A.

Dr. Bergfeld responds:

Most drugs can cause hair loss, but only in a small percentage of individuals. Reading the adverse events sections of the drug information on each drug before taking would be helpful. In addition, there are review articles on hair loss, including telogen effluvium, which can be accessed via PubMed.gov.

Getting Reimbursed for a Wig
Q.

Maybe a question for the National Alopecia Areata Foundation: I believe the NAAF has been advocating to get wigs, at a minimum, approved for health insurance reimbursement. This is not cosmetic, especially for women. Where does that stand, and how can patients help the effort?
A.

Dr. Bergfeld responds:

All of us try to get insurance reimbursement for alopecia areata, both the totalis and universalis forms. The National Alopecia Areata Foundation Web site has a letter for making an insurance claim and a prescription for the full scalp prosthesis. Even with this, though, it can be difficult to get reimbursed. I attach the patient’s photo to the insurance request. That helps. But we need patients to advocate for this. Work with the NAAF.

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